This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network |
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This Web site is a component of the SAMHSA Health Information Network. |
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Child, Adolescent & FamilyExecutive SummaryVolume IV: Promising Practices in Wraparound for Children with Serious Emotional Disturbance and Their FamiliesIntroduction Wraparound is an approach to implementing individualized, comprehensive services within a system of care for youth with complicated multi-dimensional problems. One population for whom wraparound has proven particularly useful is those children and adolescents with severe emotional and behavioral problems. Emerging from a strong need to reduce reliance on institutional care and to eliminate the fragmented care traditionally provided to youth who are at high risk, key child leaders and the federal Center for Mental Health Services (CMHS), among others, have been engaged in significant initiatives to better understand the best provision of care for this population. Wraparound, now being disseminated across the country, is seen as a promising approach focused at the child and family level to address mental health needs more appropriately and effectively in the community. While the major initiative to develop wraparound in many states has come from the mental health system, this is an intervention for all child service sectors, with education, juvenile justice, and child welfare also taking the lead role. This monograph was developed with the support of the Child, Adolescent, and Family Branch of the Center for Mental Health Services as part of an effort to increase understanding about the status of wraparound as a relatively new and innovative approach within a system of care. In this vein, a number of major questions were posed that have been addressed over the past year in a partnership with key developers and trainers, family members, wraparound program directors, state policy makers, and researchers. Briefly, these questions include:
Developement of the Report To examine the preceding questions, an ambitious set of tasks was undertaken. Initially, a literature review was conducted to assess the existing evidence base for wraparound. From this review, key individuals were identified for a focus group that gathered for two days at Duke University during the Spring of 1998. Probably the most important effort behind the development of this report was this meeting, which was designed to achieve consensus around the definition, values, essential elements, and requirements for the practice of wraparound (See Appendix A for a list of participants). The relevance of clearly defining an intervention is to ensure that it can be recognized and replicated. Clarification of the definition, values, elements, and practice requirements for the wraparound approach could help to determine whether what is being provided is truly wraparound, and to differentiate it from other interventions. Wraparound is consistent with system of care values and is a process for care delivery within a service system. At the same time, wraparound is closely tied to other key concepts of a system of care. It is individualized care, which is also true of other interventions often associated with the term "system of care." Whether wraparound is equivalent to intensive case management has been deliberated. There are multiple approaches to case management, of which wraparound may be considered the strongest one, but this awaits research comparing approaches to case management. A survey of U.S. states and territories was conducted in order to examine in what ways and to what extent the wraparound process was being implemented across the country. Three promising programs were chosen from a number of strong candidates for site visits in order to further explore aspects of organization and implementation. This provided an opportunity for in-depth exploration of the process of implementing wraparound and identification of lessons learned from those sites that might be applicable to other communities as they engage in similar reform efforts. The information gained over the course of this project is presented in the monograph. The origins and background of the wraparound approach are presented from the perspective of one of its founders. The definition, values, elements, and requirements for practice are outlined, as agreed upon during the focus group meeting at Duke University. These delineations represent consensus among key stakeholders, in addition to the recognition that much more work needs to be done. Three model sites—Milwaukee, Wisconsin; La Grange, Illinois; and Santa Clara County, California—are discussed, with emphases on similarities and differences in their implementation of the wraparound approach. The results of the state wraparound survey are presented, followed by a description of some of the standards and fidelity measures received in response to the survey. The monograph also describes some approaches to training and quality monitoring, as well as some suggested steps to create and use tools that measure wraparound fidelity. Finally, results of our literature search are presented in the form of a review of wraparound studies conducted to date. Observations of Best Practices The examination of wraparound with multiple and diverse partners (families, developers, administrators, policy makers, and researchers) communicated to the editors of this monograph the strong sense of a rapidly expanding movement to reform service delivery for children and families across the country. Enthusiasm and commitment on the part of recipients and providers are strong. There seems to be considerable consensus among these groups around definition and practice requirements, while also allowing flexibility for adaptation based on the special characteristics of communities and target populations. Those who provide training are articulate about values, elements, and practice requirements, and formal training materials are beginning to be available. Policy makers at the state level are beginning to craft wraparound into standards and devise methods for reimbursement, including managed care arrangements. Further, the research base demonstrating positive outcomes in multiple arenas is expanding, and the potential for greater growth is enhanced by attention to quality, measurement of outcomes, and demonstration of cost-effectiveness. Definition and Description of Wraparound Consensus among a range of partners was achieved during the Duke University meeting around the definition, values, essential elements, and requirements for implementation of wraparound. Each is presented in summary form below: Definition Wraparound is a philosophy of care that includes a definable planning process involving the child and family that results in a unique set of community services and natural supports individualized for that child and family to achieve a positive set of outcomes. Values An ecological perspective guides wraparound. This means that development occurs in the context of interactions between the child and his/her environment. To increase healthy functioning, environmental forces, including the family, the community, and the service system, must support the strengths of the child and family. Values include voice and choice for the child and family, compassion, flexibility, and the core values of the system of care. (See Appendix B). Essential Elements Ten essential elements of wraparound were identified:
Practice Requirements In addition, 10 practice requirements were identified:
Further operationalization of wraparound will benefit future training, quality monitoring, and research efforts. As wraparound is adapted for new child populations, organizations, or financing mechanisms, clear articulation of change will be important. The Organization and Spread of Wraparound Wraparound is actively being adopted across the country. Eighty-eight percent of states and territories report use of the wraparound approach, although it is unlikely that most operate consistently with the definition, values, elements, and requirements defined in this monograph. The wraparound approach, as designated by states, is serving a large number of youth across the country — an average of 3,800 youth per state where estimates were provided. By and large, wraparound is initiated and led by the mental health sector. However, in several states, either child welfare or education are assuming the lead role. Many other human service sectors participate actively including juvenile justice, substance abuse, and developmental disabilities. Quite different types of organizational approaches (e.g., schools, private child welfare agencies, and multi-system managed care agencies) are observed, as seen in the three examples of site models. Although details such as the composition of the community team or additional service components may vary, it is apparent that these varied approaches are able to address uniquely and individually the same values, elements, and requirements of the wraparound approach. Wraparound is quite amenable to managed care, particularly given the ability to provide flexible funds rather than having to bill for categorical services that may not match the needs of children and families. Wraparound initiatives have stressed that the availability of flexible funds is critical. However, an ability to access flexible funds can be a problem when wraparound is paid for solely by Medicaid on a fee-for-service basis. Successful implementation of wraparound is dependent on the availability of and access to adequate community services (both formal and informal). When critical services (e.g., respite care) do not exist, the wraparound initiative may have to facilitate development of them. Wraparound also needs to be understood in a consistent manner across system, program, and practice levels in order to work. Clear policy and strong training within wraparound programs are consistent with measurable positive outcomes and quality of care. Such programs are likely to be seen as models and tapped for policy and training leadership state-wide and nationally, potentially underscoring the importance of building increased capacity and support for leadership to take on as additional functions. Training and Quality Monitoring To date, little has been done to identify the knowledge, skills, and training needed to accredit either programs or individuals as wraparound providers. The great majority of wraparound initiatives obtain training from a small cadre of national experts, suggesting a need to enhance training resources, particularly for ongoing inservice training. Training models for wraparound also are beginning to emerge in graduate schools, and further spread is necessary to prevent drastic retraining in the future. In addition, several states and organizations have developed formal training curricula that could be utilized more broadly if available and accessible in a published or Internet-accessible form. Other training tools are becoming available, including a manual and several training videos. Some states have developed standards for wraparound. Existing ones tend to be quite general and could be enhanced with agreement within the field about the specification of wraparound. Few standards include benchmarks for monitoring purposes. Examples of well designed and tested standards should be made available to states that are in the process of developing their own specific standards. Early experience with developing and testing fidelity measures also has been reported. This requires further development to ensure that wraparound, as described, is actually being provided. Research Wraparound has been evaluated in 9 states through a total of 16 studies to date. Appropriate to early research on an innovative intervention, these studies are largely descriptive with the exception of two randomized clinical trials, calling for more evaluation and controlled research as dissemination continues across the country. The early studies consistently point to a number of positive outcomes: reduced restrictiveness of living situations, reduced cost of care in several studies, and improvement in social, school, and community functioning. Conclusions and Recommendations For Further Development of Wraparound Policy To sustain wraparound approaches and to ensure the integrity and quality of the wraparound process require strategies at multiple levels: policy, community, and practice. Policies and legislation at the federal and state level need to support the wraparound philosophy and practice, thus facilitating development of integrated service systems and planning, and the blending of formal and informal services, as well as funding streams and incentives. Standards and quality assurance mechanisms need to be built in at the national and state level and through accrediting bodies and state agencies. At the community level, system change needs to support the development of community collaborative structures, cross-agency policies to support governance structures, the establishment of a broker organization for wraparound, the development of child and family teams that are cross-system, and the flexing and blending of dollars and funding streams. Training Training in the wraparound approach and its role in systems of care should occur such that wraparound is understood as a legitimate, replicable service approach that includes a set of interventions by policy makers, administrators, mid-level managers, and supervisors, as well as front-line practitioners. Training needs to involve state and local level agencies and all systems including mental health, substance abuse, social services, child welfare, education, early childhood, education, juvenile justice, and law enforcement. Attention to training for undergraduate and graduate students moving toward careers in human service sectors is also a high priority. Training curricula must be comprehensive to include values, operational elements, and wraparound requirements, as well as cross-system issues (including jurisdictional issues, services, and financing), mentoring and coaching strategies, and evaluation strategies. Training can occur through a range of modalities including courses, supervision, coaching, mentoring, internships, certification, and degree programs. Research Research is critical to the ongoing development and implementation of wraparound, furthering knowledge about this service approach. Fertile areas for research include: elements essential to achieving positive and measurable outcomes, comparison of models in different settings and/or with different populations, and cost-effectiveness related to different funding mechanisms. Standardized data collection and information tracking procedures could contribute information for effective training strategies for disseminating the wraparound process. Ensuring the integrity of the wraparound process through monitoring its fidelity will be critical to the preceding types of research. |
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